ZONE:

Topping versus bottoming

on 16 Aug 2013 by Victorian AIDS Council Gay Men's Health Centre

Many HIV negative men think it's safe for them to fuck without condoms, even with a partner who is, or might be, HIV positive, as long as they are the top (i.e. the guy doing the fucking). But is choosing to be the active partner a reliable technique for avoiding getting HIV during unprotected anal sex?

Many HIV negative men think it's safe for them to fuck without condoms, even with a partner who is, or might be, HIV positive, as long as they are the top (i.e. the guy doing the fucking).

Similarly, many HIV-positive men think they can fuck without condoms without putting an HIV negative partner at risk, so long as the HIV-positive guy is the one being fucked.

Many men believe this because they have heard that it is easier for HIV to travel from the guy who is fucking to the guy being fucked than the other way round.

Although it is easier for HIV to pass from the top to the bottom, many men become HIV-positive as the top (i.e. active partner) when fucking without a condom. The best way to prevent HIV is to use condoms and water based lube.

Why is the guy being fucked more at risk when fucking without condoms?

The guy being fucked is more at risk during unprotected sex for two reasons:

• HIV is carried in body fluids including semen. When someone comes inside you, if they are HIV-positive then the HIV in their semen is also inside you and can enter your bloodstream through the sensitive lining of the anus.

• The sensitive lining of the anus is more susceptible than the skin of your cock to cuts and abrasions caused by friction during anal sex. These cuts and abrasions in the anus offer any HIV present in cum or pre-cum an entry point into the receptive partner's bloodstream.

Does that mean unprotected anal sex is safe for the top?

No. Choosing to be the active partner is NOT a reliable technique for avoiding getting HIV during unprotected anal sex. Many men have become HIV positive as a result of being the top during unprotected sex.

How can HIV enter the active partner's penis?

HIV in body fluids in the bottom's anus can enter the top's cock through the urethra (i.e. the opening at the tip of the penis through which urine and cum passes). It can also enter the cock through any cuts or abrasions caused by friction during sex, or through sores or other irritations caused by the presence of another STI (Sexually Transmitted Infection).

There are other risk factors.

There are other factors that can significantly affect whether being top or bottom reduces the degree of risk of having unprotected sex. For example:

Whether he tops or bottoms, an HIV negative man is more at risk of getting HIV if he already has another sexually transmitted infection (STI) (e.g. syphilis or Chlamydia). The sores or lesions caused by an STI can create an effective gateway for HIV to pass from one body to another during sex. Even if there are no apparent symptoms, an STI can still increase your susceptibility to HIV. As STI's often don't have symptoms, the only way to know if you have one or not is to get a regular sexual health check.

If an HIV positive man has another STI this further increases the risk to his partner. This is because the increased burden of a second STI on an HIV-positive person's immune system means it is less able to suppress the amount of HIV in the body. This results in a much higher viral load (i.e. the amount of HIV in the body), which makes him more infectious. (If you are HIV-positive, having another STI will also have a more serious impact on you and can progress much faster).

The viral load of an HIV-positive person will commonly fluctuate over time, affecting their level of infectiousness. For example, people have a particularly high viral load when they first become HIV positive, as the body's immune system has not yet begun to fight the virus. This makes them particularly likely to transmit the virus during unprotected sex, especially if they are unaware that they have become HIV-positive.

The rougher the fucking, the greater the risk of HIV transmission during unprotected sex. Rough sex increases the likelihood of cuts or abrasions to either partner, increasing the opportunity for HIV to pass from one person to another via semen or blood.

Is there any safe way to have unprotected anal sex?

The only reliably safe way to have anal sex without condoms is with a long-term partner with whom you have been tested for HIV together, then tested again three months later. For this process to work, partners need to continue using condoms with each other (and with any casual partners) until they get the second test results.

If both partners' test results are still negative the second time, and neither of them has had any risk of exposure to HIV in the period between the two tests, then they can be reasonably sure that they are both HIV negative and stop using condoms with each other.

In order to work, the process requires a high level of discussion and trust between the partners about always using condoms if they have sex with anyone else and being honest with each other if one of them breaks this agreement.

Many HIV-positive men choose to have unprotected sex with other HIV-positive men. Although this puts neither partner at risk of being exposed to HIV for the first time, HIV positive men who choose to fuck without condoms run the risk of getting other potentially serious STIs such as syphilis or gonorrhoea.